Drug Court Progress Report Services Provided

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Youth First Initial*

Youth Last Initial*

Youth Court ID*

Treatment Provider Agency Name*

Treatment Provider Employee name*

Is Youth on this week's Docket?*

Yes

No

Current Hearing Date*

Current Hearing Date

Enter Services Provided - Appointments

Yes

No

Please enter Appointments attended or missed/Services Provided

New: Does this youth's funding source apply to all Services?*

Yes

No

If all appointments use the same funding source, click Yes and enter to the right. It must be Medicaid, Insurance, IDF or JDC/RF funding.

Youth's Main Funding Source*

If Other (Specify) funding source, it must be entered within each appointment. Click No on previous question.

Treatment Provider Notes

900 character limit (about 9 lines)

Seven Challenges Journal

Enter Seven Challenges Journal the youth is working on that you wish to share with the team.

Change Level of Care?*

Yes

No

Enter Initial or Change in Level of Care

Effective / Active Date*

Effective / Active Date

Level of Care

Group or Individual Service*

Group

Individual

Both Group & Individual

Other (Parent, Caregiver, Family/Support People)

Residential Group Date Range

None

Funding Source /Participants:

Enter Specific Funding Source?

Client

Parent

Caregiver

Other

Date of Service*

Date of Service

Residential Group Dates*

Residential Group Dates Start Date

—

Residential Group Dates End Date

Enter Residential Range of Dates (span must be at least 2 days)

Attendance*

Attended

Excused

Not Excused

Service to be Provided*

Enter the type of Service Provided, even if Client was absent for this service.(Seven Challenges, Case Management, Prosocial Activity, Cognitive-Behavioral Therapy/Motivational Enhancement Therapy, Other).

Other Service (Specify)

Funding Source*

Enter funding source for this service.

Other Specify Funding Source

Another Appointment /Service?*

Yes

No

2. Group or Individual Service*

Group

Individual

Both Group & Individual

Other (Parent, Caregiver, Family/Support People)

Residential Group Date Range

Funding Source /Participants:

Enter Specific Funding Source?

Client

Parent

Caregiver

Other

Date of Service*

Date of Service

Residential Group Dates*

Residential Group Dates Start Date

—

Residential Group Dates End Date

Enter Residential Range of Dates

Attendance*

Attended

Excused

Not Excused

Service to be Provided*

Enter type of Service to be Provided

Other Service (Specify)

Funding Source*

Enter funding source for this service.

Other Specify Funding Source

Another Appointment /Service?*

Yes

No

3. Group or Individual Service*

Group

Individual

Both Group & Individual

Other

Residential Group Date Range

Funding Source /Participants:

Enter Specific Funding Source?

Client

Parent

Caregiver

Other

Date of Service*

Date of Service

Residential Group Dates*

Residential Group Dates Start Date

—

Residential Group Dates End Date

Enter Residential Range of Dates

Attendance*

Attended

Excused

Not Excused

Service to be Provided

Enter type of Service to be Provided

Other Service (Specify)

Funding Source*

Other Specify Funding Source

Another Appointment /Service?*

Yes

No

4. Group or Individual Service*

Group

Individual

Both Group & Individual

Other

Residential Group Date Range

Funding Source /Participants:

Enter Specific Funding Source?

Client

Parent

Caregiver

Other

Date of Service*

Date of Service

Residential Group Dates*

Residential Group Dates Start Date

—

Residential Group Dates End Date

Enter Residential Range of Dates

Attendance

Attended

Excused

Not Excused

Service to be Provided*

Enter type of Service to be Provided

Other Service (Specify)

Funding Source

Other Specify Funding Source

Another Appointment /Service?*

Yes

No

5. Group or Individual Service*

Group

Individual

Both Group & Individual

Other

Residential Group Date Range

Funding Source /Participants:

Enter Specific Funding Source?

Client

Parent

Caregiver

Other

Date of Service*

Date of Service

Residential Group Dates*

Residential Group Dates Start Date

—

Residential Group Dates End Date

Attendance

Attended

Excused

Not Excused

Service to be Provided*

Enter type of Service to be Provided

Other Service (Specify)

Funding Source*

Other Specify Funding Source

Another Appointment /Service?*

Yes

No

6. Group or Individual Service*

Group

Individual

Both Group & Individual

Other

Residential Group Date Range

Funding Source /Participants:

Enter Specific Funding Source?

Client

Parent

Caregiver

Other

Date of Service*

Date of Service

Residential Group Dates*

Residential Group Dates Start Date

—

Residential Group Dates End Date

Attendance

Attended

Excused

Not Excused

Service to be Provided*

Enter type of Service to be Provided

Other Service (Specify)

Funding Source*

Other Specify Funding Source

Another Appointment /Service?*

Yes

No

7. Group or Individual Service*

Group

Individual

Both Group & Individual

Other

Residential Group Date Range

Funding Source /Participants:

Enter Specific Funding Source?

Client

Parent

Caregiver

Other

Date of Service*

Date of Service

Residential Group Dates*

Residential Group Dates Start Date

—

Residential Group Dates End Date

Attendance

Attended

Excused

Not Excused

Service to be Provided*

Enter type of Service to be Provided

Other Service (Specify)

Funding Source*

Other Specify Funding Source

Another Appointment /Service?*

Yes

No

8. Group or Individual Service*

Group

Individual

Both Group & Individual

Other

Residential Group Date Range

Funding Source /Participants:

Enter Specific Funding Source?

Client

Parent

Caregiver

Other

Date of Service*

Date of Service

Residential Group Dates*

Residential Group Dates Start Date

—

Residential Group Dates End Date

Attendance

Attended

Excused

Not Excused

Service to be Provided*

Enter Service to be Provided

Other Service (Specify)

Funding Source*

Other Specify Funding Source

Another Appointment /Service?*

Yes

No

9. Group or Individual Service*

Group

Individual

Both Group & Individual

Other

Residential Group Date Range

Funding Source /Participants:

Enter Specific Funding Source?

Client

Parent

Caregiver

Other

Date of Service*

Date of Service

Residential Group Dates*

Residential Group Dates Start Date

—

Residential Group Dates End Date

Attendance

Attended

Excused

Not Excused

Service to be Provided*

Enter Service to be Provided

Other Service (Specify)

Funding Source*

Other Specify Funding Source

Another Appointment /Service?*

Yes

No

10. Group or Individual Service*

Group

Individual

Both Group & Individual

Other

Funding Source /Participants:

Enter Specific Funding Source?

Client

Parent

Caregiver

Other

Date of Service*

Date of Service

Attendance

Attended

Excused

Not Excused

Service to be Provided*

Enter Service to be Provided

Other Service (Specify)

Funding Source*

Other Specify Funding Source

Another Appointment /Service?*

Yes

No

11. Group or Individual Service*

Group

Individual

Both Group & Individual

Other

Funding Source /Participants:

Enter Specific Funding Source?

Client

Parent

Caregiver

Other

Date of Service*

Date of Service

Attendance

Attended

Excused

Not Excused

Service to be Provided*

Enter Service to be Provided

Other Service (Specify)

Funding Source*

Other Specify Funding Source

Another Appointment /Service?*

Yes

No

12. Group or Individual Service*

Group

Individual

Both Group & Individual

Other

Funding Source /Participants:

Enter Specific Funding Source?

Client

Parent

Caregiver

Other

Date of Service*

Date of Service

Attendance

Attended

Excused

Not Excused

Service to be Provided*

Enter Service to be Provided

Other Service (Specify)

Funding Source*

Other Specify Funding Source

Another Appointment /Service?*

Yes

No

13. Group or Individual Service*

Group

Individual

Both Group & Individual

Other

Funding Source /Participants:

Enter Specific Funding Source?

Client

Parent

Caregiver

Other

Date of Service*

Date of Service

Attendance

Attended

Excused

Not Excused

Service to be Provided*

Enter Service to be Provided

Other Service (Specify)

Funding Source*

Other Specify Funding Source

Another Appointment /Service?*

Yes

No

14. Group or Individual Service*

Group

Individual

Both Group & Individual

Other

Funding Source /Participants:

Enter Specific Funding Source?

Client

Parent

Caregiver

Other

Date of Service*

Date of Service

Attendance

Attended

Excused

Not Excused

Service to be Provided*

Enter Service to be Provided

Other Service (Specify)

Funding Source*

Other Specify Funding Source

Another Appointment /Service?*

Yes

No

15.Group or Individual Service*

Group

Individual

Both Group & Individual

Other

Funding Source /Participants:

Enter Specific Funding Source?

Client

Parent

Caregiver

Other

Date of Service*

Date of Service

Attendance

Attended

Excused

Not Excused

Service to be Provided*

Enter Service to be Provided

Other Service (Specify)

Funding Source*

Other Specify Funding Source

External Agency Referral

Yes

No

Were referrals made from your agency to an external provider? (enter up to 3)

Date of Referral

Date of Referral

1a. Please Enter the Date referred

Agency / Organization Referred To

1b. Name of the Agency or Organization that an external referral was made to

Reoffered to this organization for the following services

Substance Abuse Treatment

Behavioral / Mental Health

Education

Employment

Family Services

Prosocial / Recreational

Other Services

Other Services

1d. Please describe other services

Date of Referral

Date of Referral

2a. Please Enter the Date referred

Agency / Organization Referred To

2b. Name of the Agency or Organization that an external referral was made to

Services Provided by this Agency / Organization

Substance Abuse Treatment

Behavioral / Mental Health

Education

Employment

Family Services

Prosocial / Recreational

Other Services

Other Services

2d. Please describe Other Services

Date of Referral

Date of Referral

3a. Please enter the Date referred

Agency / Organization Referred To

3b. Name of the Agency or Organization that an external referral was made to

Services Provided by this Agency / Organization

Substance Abuse Treatment

Behavioral / Mental Health

Education

Employment

Family Services

Prosocial / Recreational

Other Services

Other Services

3d. Please describe Other Services

Any Drug Screens?*

Yes

No

Please enter Drug Screen results.

Drug Name*

Other Drug

Please specify

Date of Screen*

Date of Screen

Enter Date of Drug Screening

Result of Screen*

Negative

Positive

DNG

Pending

Enter Drug Test Result

Creatine?

Normal

Diluted

Another Test ?*

Yes

No

Drug Name

Other Drug

Please specify

Date of Screen*

Date of Screen

Result of Screen*

Negative

Positive

DNG

Pending

Creatine?

Normal

Diluted

Another Test?*

Yes

No

Drug Name

Other Drug

Please specify

Date of Screen*

Date of Screen

Result of Screen*

Negative

Positive

DNG

Pending

Creatine?

Normal

Diluted

Another Test?*

Yes

No

Drug Name

Other Drug

Please specify

Date of Screen*

Date of Screen

Result of Screen*

Negative

Positive

DNG

Pending

Creatine?

Normal

Diluted

Another Test?*

Yes

No

Drug Name

Other Drug

Please specify

Date of Screen*

Date of Screen

Result of Screen*

Negative

Positive

DNG

Pending

Creatine?

Normal

Diluted

Discharge Status

If applicable,enter Discharge information

If Other, Please Specify

Date of Discharge

Date of Discharge

End of Treatment Provider Info

School Attendance Issues ?

Yes

Suspended, Expelled, Truancy Hearing

School Attendance/Behavior Note

Drop_Notes

Enter Excused Drop, or Other Drop Notes

Breathalyzer

Yes

Breathalyzer Date

Breathalyzer Date

Prior Court Orders

Attend Sober Support Activities

Community Service Hours

Complete phase advancement paper

House Arrest

House Arrest w/Surveillance

Number of Community Service Hours assigned

Number of Sober Support Activities

Other Court Orders

Prior Drop Schedule

Red

Yellow

Green

Drop schedule changed, or used Normal Schedule based on Phase in program.